Steroid shots disappoint in back pain study

Older adults who get steroid injections for degeneration in their lower spine may fare worse than people who skip the treatment, a small study suggests.

Older adults who get steroid injections for degeneration in their lower spine
may fare worse than people who skip the treatment, a small study suggests.

The research, published recently in the journal Spine, followed 276
older adults with spinal stenosis in the lower back. In spinal stenosis, the
open spaces in the spinal column gradually narrow, which can put pressure on
nerves. The main symptoms are pain or cramping in the legs or buttocks,
especially when you walk or stand for a long period.

The treatments range from "conservative" options like anti-inflammatory
painkillers and physical therapy to surgery. People often try steroid injections
before resorting to surgery. Steroids calm inflammation, and injecting them into
the space around constricted nerves may ease pain -- at least temporarily.

Some pain relief

In the new study, researchers found that patients who got steroid injections
did see some pain relief over four years. But they did not fare as well as
patients who went with other conservative treatments or with surgery right
away.

And if steroid patients eventually opted for surgery, they did not improve as
much as surgery patients who'd skipped the steroids.

It's not clear why, said lead researcher Dr Kris Radcliff, a spine surgeon
with the Rothman Institute at Thomas Jefferson University, in Philadelphia.

"I think we need to look at the results with some caution," he said. Some of
the study patients were randomly assigned to get steroid injections, but others
were not - they opted for the treatment. So it's possible that there's something
else about those patients that explains their worse outcomes, Radcliff said.

On the other hand, he said, steroid injections themselves might hamper
healing in the long run. One possibility is that injecting the materials into an
already cramped space in the spine might make the situation worse, once the
initial pain-relieving effects of the steroids wear off, Radcliff explained.

"But that's just our speculation," he said.

A pain management specialist not involved in the work said it's impossible to
pin the blame on epidural steroids based on this study. For one, it wasn't a
randomised clinical trial, where all patients were assigned to have steroid
injections or not have them, said Dr Steven Cohen, a professor at Johns Hopkins
School of Medicine, in Baltimore.

'Tool in the toolbox'

The patients who opted for epidural steroids "may have had more
difficult-to-treat pain, or a worse pathology," Cohen said.

He also noted that there is evidence from other research that epidural
steroids can help some patients delay spine surgery.

"Epidural steroids won't work for everyone, but they're going to work for
some people," said Cohen, adding that he would "absolutely" suggest patients
give them a shot if they want to put off surgery.

Epidural steroids should be seen as a "tool in the toolbox", said Dr Eric
Mayer, of the Center for Spine Health at the Cleveland Clinic, in Ohio.

If the goal is to get some symptom relief and possibly delay surgery, then
patients may want to try the injections, according to Mayer.

"This study is interesting," he said. "But it really does nothing to inform
medical practice."

Epidural steroids have been the subject of some press recently. US officials
are currently investigating a deadly outbreak of fungal meningitis linked to
epidural steroids produced by one Massachusetts pharmacy.

No evidence of infections

The patients in the current study came from 13 spine treatment centres in 11
US states. Radcliff said there was no evidence of infections or other serious
side effects from the treatment. "So, it did appear to be safe," he said.

Radcliff said he wouldn't discourage the use of steroid injections for
patients who want to try them. "It's still reasonable to offer this as an
option," he said. "These patients did improve; they just didn't improve as much
as the others."

He also pointed out that spinal stenosis is just one cause of low back and
leg pain. Other conditions can pinch a nerve and cause similar symptoms, such as
a herniated disc.

Cohen said that in general, patients with a herniated disc respond better to
steroid injections than those with spinal stenosis - though people with a
herniated disc also have a good shot at getting better with no treatment.

Unlike a herniated disc, spinal stenosis is a progressive condition, and it
won't be "cured" with any treatment. Even after surgery, Cohen said, your
symptoms may well come back at some point.

With epidural steroid injections, there's no consensus on how long you can
keep getting them.

But the general guideline is to have no more than three to six injections in
a year, Cohen said - though that's based on expert opinion rather than hard
evidence. And just one injection at a time seems to be enough, Cohen noted. Some
doctors are in the habit of doing three in one go, but there's no evidence that
it benefits patients.

If you do go for epidural steroid injections, it would be wise to make sure
your insurance covers it: in the United States, one injection can cost a few
hundred dollars.

Ask the Expert

Susan qualified as a Physiotherapist in 1990, and completed her master’s degree in Physiotherapy in 2013 at the University of Pretoria. She has a special interest in human biomechanics, as well as the interaction between domestic and work-related ergonomics.

posted on 28-01-2015

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